In a healthy person, the skin has a more or less uniform coloration in a particular area. On it there is no pattern or inclusions of a different color, with the exception of moles and traces of insect bites. But in some people under the influence of cold on the body appears an unusual bluish or burgundy pattern in the form of an unexpressed mesh, outwardly reminiscent of marble. It is this phenomenon in medicine called reticular livedo or Livedo reticularis.
Perhaps the reader has heard other names of this condition, which is the usual physiological response of peripheral vessels to the cold. Such names as marble skin or reticular ledo mean all the same pathology, although it is possible to baptize this condition pathologically with great stretch.
Causes of the reticulated
To call to the eye any specific reason for the appearance on the skin of a marble pattern is simply impossible. This is due to the fact that the grid has two mutually exclusive forms:
Idiopathic livedo. This is an unstable physiological reaction of the organism, which arises under the influence of cold air and passes when the heat affects the body. There are no irreversible morphological changes with the structure of the vascular walls.
The pattern appears on open parts of the body, which are not protected by clothing from the cold. It is this form of livedo that can be seen on the body of young women.
The causes of the emergence of idiopathic livedo are still a mystery for doctors, although it is thoroughly known that the marble pattern appears due to vasospasm. Why do some people have this picture, and others do not, remains incomprehensible. But since this phenomenon in the absence of any pathology of the vessels is not considered a disease and does not require treatment, its study is not given much importance.
Symptomatic. The very name of the state indicates that the mesh pattern on the skin is one of the symptoms of some pathologies, in which the inflow of blood to the skin integuments is disturbed.
A mesh of a symptomatic type can be observed in the following pathologies:
High blood viscosity, heart failure, paralysis, Sneddon's syndrome, cholesterol embolism syndrome, thrombocytosis and some other diseases in which there is a violation of blood flow through the vessels as a result of obstruction.
Atherosclerosis of vessels, vasculitis: nodular polyarteritis, lupus erythematosus, cryoglobulin vasculitis (cryoglobulinemia), rheumatoid arthritis, AFL syndrome, lymphoma, dermatomyositis, syphilis, tuberculosis, pancreatitis and other pathologies that undergo changes in the vascular wall.
The risk factors for the appearance of a net liver can be considered:
Acceptance of certain medications. For example, quinine, amantadine, quinidine, noradrenaline.
Hypoteria in the mother, which can be transmitted to the fetus. After delivery, the net liver, along with such symptoms as cold hands and feet, apathy to the surrounding, drowsiness, etc. Can be seen in a baby with a low level of thyroid hormones.
Autoimmune thyroiditis, in which, like in vasculitis, a reticulum may appear as a consequence of hypothyroidism, especially if the patient has light thin skin.
The very word "livedo" in Latin means a bruise. A bruise is nothing more than a limited accumulation of blood in the subcutaneous layer or simply a hemorrhage. Usually bruises, or bruises, are formed due to tissue damage, during which the capillaries break. Blood, flowing out of the vessels, accumulates in the subcutaneous tissue and outwardly visible as a blue part of the body.
When livedo extensive subcutaneous hemorrhage is not observed. Under the influence of certain stimuli (most often cold), there is a vasospasm characterized by impaired capillary blood flow, resulting in stagnation of blood in the veins, and the vessels become visible through the layers of the skin.
Livedo belongs to the category of vascular nerves spastico-atonic form. The vascular pattern at the same time resembles either the branching of the tree (a tree-like liveno ), or the mesh or the surface of the marble (reticular or reticular livedo ). With a reticular variety of liver, blood stasis causes a thickening of the endothelium in the venous knee of the capillaries, and this part of the vessel begins to shine through the skin. It is this moment that determines the kind of drawing that we see on the surface of the body.
According to statistics, the reticulum occurs more often than treelike and other species of livedo (with a mottled or bizarre pattern). Such a vascular response is more typical for girls aged 20-23 years, although sometimes this pattern can be found in people (more often women) older (up to 50 years) with a delicate skin of light shade.
A specific vascular pattern appears mainly in the region of the lower leg and thighs, although sometimes it can also be seen on the forearms, lateral surfaces of the trunk, hands and buttocks.
Symptoms of the reticulated
The main feature of the net is the appearance on the body and limbs of a marble pattern with a bluish tinge that becomes more pronounced and bright under the influence of cold or rapid temperature changes, and disappears when pressed. Idiopathic livedo practically does not appear in the summer. It "prefers" colder periods.
The color of the pattern can range from reddish-violet to burgundy and even blue. Clear boundaries for the "setochki" no. The cells of the "grid" can have a round or oval shape. Their diameter can reach 20 mm. The skin inside the so-called cells can be of ordinary color or slightly paler than the rest.
Idiopathic reticulum is characterized by a certain symmetry. The figure does not appear on one limb, but immediately on both. It can be located on the buttocks or on the sides on the trunk. By the way, on the arms and legs, sometimes some unbalanced specks can also be observed. For symptomatic pathology with a marble pattern, symmetry is not characteristic.
People with idiopathic livedo can freeze in a fairly warm room, they have a broken perception of temperature. The hands and feet of these patients are usually cold to the touch due to impaired blood circulation. When a vascular reticulum can be felt mild pain and tingling. Sometimes there is a violation of sensitivity and numbness on the skin.
Symptomatic liverdo always is the first sign of some pathology, in which there is an obstructive disorder of blood flow or morphological changes in blood vessels, as a result of which the blood flow is again disturbed. In this case, other symptoms, characteristic of the existing pathology, join the figure on the body.
For example, if a person has increased blood viscosity, he suffers from headaches, tinnitus, chronic fatigue, drowsiness and depression. Such patients have an increased risk of nasal bleeding, often high blood pressure, there are certain problems with vision. Patients report a violation of the sensation of the body with tingling and "goose bumps". Along with the reticular liver, they can show noticeable venous nodules.
Vasculitis is characterized by the appearance on the skin of a marble pattern, which is called a lyvedo vasculitis (otherwise, livedo angiitis). The pattern is present constantly and is typical for many types of vasculitis. It resembles a loopy net that, under the influence of cold, becomes brighter, but does not disappear from heat, as in an idiopathic livedo. The disease progresses, and the liver becomes more pronounced, foci of hemorrhages and necrosis appear on the mesh, with the subsequent formation of small ulcers.
In severe cases, there is a formation in the vascular network of painful nodules prone to necrosis and the formation of deep ulcers in their place, which heal for a long period. Ulcers heal with the formation of light scars surrounded by skin, more dark than usual.
Patients complain of constant chilliness. They note unpleasant drawing pains in the extremities, while in the area of ulcers and nodular densities the pain has a pronounced pulsating character.
The appearance of livedo angiitis was noted predominantly in female subjects.
In Seddon syndrome, which is a kind of antiphospholipid syndrome (AFL), along with the marble pattern on the skin, symptoms are observed that indicate high blood pressure and thrombosis of the vessels of the brain. For the AFL itself, venous and arterial thrombosis, lesions of the central nervous system and heart (coronary artery thrombosis) are characteristic.
With cholesterol embolism, the appearance of a vascular pattern may for some time remain the only symptom. And the diagnosis is based on a skin biopsy.
Symptoms of vascular atherosclerosis may differ depending on the vessels of which area were affected.
If the net liver is accompanied by excessive sweating, cyanosis of the skin, chills, violation of keratinization, it is worthwhile to consult a doctor, since such symptoms may indicate various pathologies associated with blood circulation disorders.
Physiological behavior in infants
Newborn babies are particularly delicate and thin skin, which normally has an even color. If, on the body of the baby, parents notice a bluish pattern in the form of a reticulum, this scares them very much, although the appearance of the net liver is not always associated with the pathologies of health in the case of a baby, like an adult.
In a child under 6 months, the periodic appearance and disappearance of a strange pattern on the skin can be related to the insufficient formation of the immune system, the thermoregulatory system, and the location of the vessels near the thin skin. Therefore, when exposed to cold air and because of the temperature difference, the body reacts with the appearance of a marble pattern. It disappears as soon as the body adapts to the temperature of the environment, but this process in infants is slower than in adults.
A marble pattern on the baby's skin can result from prematurity or birth hypoxia. His appearance is also associated with overfeeding the child, which provokes an increase in blood volume and vascular tension. In thin children with low weight, the appearance of a net liver is considered a variant of the norm.
But a reticular liver in a baby can also be a manifestation of such rare congenital pathologies as telagioectatic marbled skin, also called generalized phlebectasia, and a mysterious skin marbling syndrome.
A permanent or periodically appearing leafed liver can be observed in children with heart defects, congenital glaucoma, genetic abnormalities, vegetovascular disorders. Marble pattern can also appear with anemia, rickets, non-inflammatory diseases of the brain.
Sometimes with age, this symptom disappears and no longer reminds oneself. If this occurs before the age of 5 months, then there is nothing to worry about. If, however, the pattern on the skin remains for a longer time, it is best to conduct a survey of the baby to identify the pathology that caused this symptom at its early stage.
Complications and consequences
Idiopathic reticulum is not a danger to human life and health. Thus, the body and in particular the vascular system reacts to the cold. When warming, the marble pattern disappears without a trace. And since there are no structural changes in the vessels during this time, such a condition does not cause harm to health either.
But this is the case if the lidado vasculitis is not attached to the idiopathic liver, for which the formation of nodules and ulcers is characteristic. And any skin damage is considered as a life-giving soil for bacterial infection. Especially if it is a question of deep and hard-healing wounds.
Sometimes, in addition to sores, a swelling of the tissues is also observed in the area of the appearance of the net liver, which is considered a complication of the reticulated liver.
The consequences of the retina depend on the pathology that caused the appearance of the corresponding figure on the body. The most dangerous is the formation (and, the more so, the rupture of the thrombus). But other pathologies in which there is a disturbance of blood circulation, carry little pleasure in themselves, because they cause oxygen starvation of various tissues and organs, as a result of which they can no longer perform their functions normally.
If it comes to violations of the coronary and cerebral blood flow, then here we see the situation dangerous not only for health, but for the life of the patient.
Diagnostics of the reticulated
If a person observes the appearance on the skin of a strange pattern that becomes brighter under the influence of the cold, and becomes fainter on warming up to complete extinction, it is not so easy to determine whether this condition is associated with the usual physiological reaction of the organism to the eye or is a sign of serious systemic diseases.
If the appearance of the pattern is attributed only to the effect of low temperatures at which a vasospasm occurs, then, most likely, one should not worry. But if the pattern does not disappear when warming, and only slightly turns pale, this is an occasion to turn to a medical institution for consultation of a doctor and examination of the body, and vessels in particular. Still, the figure that we see is nothing more than a vascular mesh that should not be visible in the normal state.
The doctor-specialist during the examination conducts the examination of the patient, palpation of the affected area, listening and tapping of the vaginal space, measures blood pressure and pulse, conducts anamnesis. If the patient is a small child, it is necessary to find out what diseases the mother suffered before and during pregnancy, how the pregnancy went, how the delivery was at what time, when the figure on the baby's body appeared and whether there are any other warning signs, especially those about which we have already mentioned above.
The patient is given tests. Usually this is a general and biochemical blood test. The gas composition of the blood is determined to clarify the oxygen saturation of the blood. To assign safe treatment and determine the functionality of the kidneys, urinalysis can also be assigned.
The doctor can also prescribe an FVD analysis. The study of the functions of external respiration includes spirometry, pneumotachography and spirography, with the help of which the lung function is evaluated, and hence the volumes of oxygen entering the blood.
The methods of instrumental diagnostics, which can be assigned to a reticular live, include:
angiography (assessment of blood supply to organs) of blood vessels,
phonoangiography (assessment of vascular noise in blood flow disturbances) of vessels,
volumetric sphygmography (determines the oscillations of the vascular wall for evaluation of the main blood flow);
rheovasography (assessment of central and peripheral
skin electrometry and thermography (evaluation of peripheral circulation due to changes in skin temperature);
Duplex scanning with ultrasound dopplerography (assessment of the general condition of blood vessels and blood flow in them),
Ultrasound of vessels (determines the area of vessel stenosis),
Radioisotope study (studies blood filling of peripheral vessels),
Nuclear magnetic resonance imaging with contrasting (assessment of the state of the vascular wall, minute blood flow, the extent of stenotic vessels, etc.).
endoscopic examination of the tracheobronchial tree, through which air enters the lungs (fibrobronchoscopy),
lymphography (assessment of lymph flow, is used in oedematous syndrome),
electro- and echocardiography.
There are other methods for assessing the condition of the main and peripheral vessels, but the above research methods are the most popular in the domestic medical institutions.
Differential diagnosis is performed with the appearance of edema (the nature of the edema and the cause) and the symptoms characteristic of various pathologies. The mesh should also be differentiated from the reticular pathologies of the skin, such as infrared and infectious erythema, poikiloderma, reticular varicose, and the like.
But first of all, it is important to distinguish between the idiopathic form of the liver and the symptomatic, associated with certain diseases, representing a threat to the health and life of the patient.
If the reticulum is not a constant symptom and is diagnosed as idiopathic, then it does not require any treatment. Such a reaction can be present for a limited time and pass with age, and can acquire a chronic form. Nevertheless, it does not carry danger to a person, which means that there is no need to treat it.
However, sometimes, if the appearance of the vascular network delivers severe discomfort, the doctor can prescribe the administration of small doses of "Acetylsalicylic acid" and "Pentoxycillin" (400 mg three times a day). Such treatment does not require hospitalization. Assign his therapist or dermatologist.
Treatment of a symptomatic diet is carried out taking into account the pathology, which caused the appearance of a marble pattern on the body.
In most cases, doctors prescribe:
Vasodilator preparations, mainly peripheral vasodilators, which ensure the normalization of blood flow due to the relaxation of the vascular walls (Pentoxifylline, Vazonit, Pentomer, etc.).
Drugs that dilute blood ("Aspirin", "Heparin", "Warfarin" and others).
Preparations of calcium.
Vitamins or vitamin-mineral complexes containing calcium, vitamins C, E, P, nicotinic acid, improving the condition of blood vessels, reducing their fragility and permeability.
At elevated pressure, drugs used to combat hypertension can be prescribed.
When vasculitis is prescribed therapy with glucocorticosteroids ("Prednisolone") and immunosuppressants ("Azathioprine", "Cyclophosphamide"), in some cases, the appointment of cytostatics, as with lymphoma.
If an inflammatory reaction takes place, non-steroidal anti-inflammatory drugs (most often Indomethacin) and antimicrobial agents are prescribed for the removal of inflammation and pain relief, with the appearance of ulcers and a site of tissue necrosis.
In some cases, if drug therapy does not produce tangible results, chemotherapy, blood purification procedures (hemosorption and plasmapheresis) can be prescribed.
With a net liver, physiotherapeutic treatment gives good results : hirudotherapy, massage, ultraviolet irradiation of the affected area with suberythmic doses (from 1/8 to 7/8 of the usual biological dose), heat exposure (mainly warm baths). Such treatment can be prescribed for both symptomatic and idiopathic livedo.
Surgical treatment with a reticular liverdo is not performed if the pathology is not associated with severe vascular diseases that are not amenable to drug treatment. Otherwise, an operation corresponding to the underlying pathology can be prescribed.
Medicines for reticular livery
Mesh, like other circulatory disorders, primarily require the appointment of drugs that relieve vasospasm and relax the vascular muscle, resulting in normal blood flow and the supply of oxygen to various organs. Such drugs are called vasodilators.
In the case of the reticular lyvedo, the problem most often lies in the peripheral vessels, and so the doctor, in the absence of other disorders, will prescribe medications from the discharge of peripheral vasodilators.
The most popular and inexpensive drug from this group is Pentoxylin. It is prescribed for various violations of the peripheral circulation, including in the reticular liver of various etiologies.
Method of application and dosage. The drug is prescribed in an amount of 2 tablets 3 times a day. The daily dose is 1200 mg. Take the medicine after eating. Tablets are not chewed, but swallowed whole, with enough water.
Contraindications. The drug is not prescribed for hypersensitivity to the drug, severe bleeding and hemorrhages in the eye, hemorrhagic diathesis, ulcerative lesions of the stomach and intestines. You can not use the drug during the acute stage of myocardial infarction.
Side effects. Patients taking the drug may complain of increased blood pressure, tachycardia, heart rhythm disturbances, bleeding, dizziness and headaches, sleep disorders, trembling in the hands, gastrointestinal disorders and stool disorders. Sometimes there are allergic reactions: rash on the skin, itching, flushing of the skin. Some patients complained of increased sweating and body temperature, visual impairment, development of conjunctivitis for no apparent reason.
Precautionary measures. The drug should be taken only as directed by a doctor under the control of blood indicators, because it can cause life-threatening conditions: anaphylactic reactions and aplastic anemia.
To dilute blood in order to improve blood flow in peripheral vessels, the usual "Aspirin" ("Acetylsalicylic acid") is used most often . This drug has anti-inflammatory and antiplatelet effect.
Method of application and dosage. With a reticulated liver, not associated with other pathologies, appoint small doses of the drug (a quarter of the pill once a day in the evening). With heart pathologies, preference is given to the drug "Aspirin cardio". The duration of treatment is established by the attending physician.
Contraindications. Do not apply the drug in the treatment of patients with acute ulcerative lesions of the gastrointestinal tract, hemorrhagic diathesis, bronchial asthma. At the time of treatment, stop breastfeeding. Do not use the drug from the category of NSAIDs in the first and third semesters of pregnancy, as well as hypersensitivity to acetylsalicylic acid and other non-steroidal anti-inflammatory drugs.
Do not prescribe the drug and children with ARI, because they are up to 15 years of age, the risk of dangerous complications is high.
Side effects. Among the side effects of the drug can be identified: irritating effect on the gastrointestinal tract with their consequent symptoms, including the development of ulcerative processes and iron deficiency anemia. In addition, there are dizziness, the appearance of noise in the ears (at low doses is unlikely), bleeding, hives, severe allergic reactions.
An effective and inexpensive preparation for strengthening blood vessels from the category of vitamins is "Ascorutin". The drug contains vitamins C and P useful for blood vessels.
Method of application and dosage. Assign a vitamin preparation of 1 tablet three times a day after meals. Tablets are not chewed, but swallowed whole, washed with water (not mineral, reducing the effectiveness of ascorbic acid, it is also vitamin C).
For the prevention of vascular diseases the drug is taken 2 times a day. Single dose - 1 tablet.
Contraindications. Do not use the drug to treat children under 3 years of age, with high blood coagulability, with hypersensitivity to at least one of the components of the drug.
Side effects. Side effects of the drug are very rare. Sometimes during the reception of "Ascorutinum" symptoms such as insomnia, pain in the head, increased blood pressure, nausea, sometimes reaching vomiting, allergic reactions are noted.
For the treatment of systemic autoimmune vascular diseases, in which the skin of the liverdo vasculitis is shown, glucocorticosteroids (GCS) are shown. One of GKS's favorite doctors is the hormone drug Prednisolone.
Method of application and dosage. The initial dose of the drug is from 20 to 30 mg with the possibility of increasing to 100 mg per day. The maintenance dose ranges from 5 to 15 mg. Two-thirds of the daily dose the patient should take in the morning and third in the evening.
Contraindications. The drug is not prescribed for patients with severe forms of arterial hypertension, heart failure, myocardial infarction, diabetes mellitus, hypothyroidism, thyrotoxicosis and Ishchenko-Cushing syndrome, with stage 3 circulatory failure, acute endocarditis, inflammatory kidney pathologies. It is forbidden to take the drug if the patient suffers from psychosis, glaucoma, ulcerative gastrointestinal lesions, osteoporosis, syphilis or acute form of tuberculosis. Contraindicated corticosteroids in the postoperative period, as well as in immunodeficient conditions ..
It is undesirable to prescribe GCS during pregnancy and in old age, with severe liver and kidney pathologies with impaired function, and also after vaccination (depending on the vaccine for 2-10 weeks).
Side effects. Since "Prednisolone" is a hormonal drug, it can provoke the development of obesity, increased body hair growth in women, malfunctions in the menstrual cycle, the appearance of acne, deterioration of the bone tissue (fragility), and psychoemotional disorders.
In addition, taking the drug may be accompanied by the formation of erosions and ulcers on the mucosa of the gastrointestinal tract, with ulcers can provoke perforation of the ulcer. Sometimes the drug becomes a cause of hemorrhagic pancreatitis, dangerous hemorrhage in the gland.
The intake of the drug can help increase blood glucose levels, worsen protective functions of the body, increase blood viscosity
Precautionary measures. The drug is addictive. It should be canceled gradually to avoid such unpleasant consequences as the development of withdrawal syndrome, adrenal insufficiency, exacerbation of the pathology, in connection with which the SCS was appointed.
If the patient has infectious pathologies, the treatment with "Prednisolone" should be carried out in conjunction with antibiotic therapy.
Alternative treatment of reticular lyedo
Treatment of a reticular liver with alternative methods is, first of all, providing heat to the area of the appearance of a vascular network. It can be wrapping or a warm bath.
Alternative treatment of vascular disorders also includes alternative recipes that help reduce blood viscosity and improve blood circulation.
It liquefies blood at the expense of a large content of vitamin C natural fresh orange juice, which should be consumed half a cup a day.
Reduces the viscosity of the blood and improves the functioning of the cardiovascular system germinated wheat. Whole intact wheat grains are washed and poured with water, leaving for several hours. Then the old water is drained and the wheat is sprinkled fresh, so that the grain does not dry out. On top, the seeds are covered with a wet napkin. Within 2 days, the seeds will be poured. You need to eat grain with a germ about 1-1.5 mm for 1 tbsp. In a day. The course of treatment is 1 month.
To strengthen blood vessels, specialists in alternative medicine recommend using honey with lemon or garlic with lean oil and walnuts. Useful is a dish of raisins, dried apricots and prunes, flavored with honey and sprinkled with nuts.
To strengthen the vessels it is useful to eat legumes, eggplants, citrus fruits, rich in vitamins C and R, black currants, and, of course, onions and garlic ..
With increased pressure, honey and lemon are also useful. To this composition can be added kalina or mineral water. You can also prepare a mixture that is insisted for 4 hours before consumption: honey, lemon pulp, carrot and beet juices taken in different amounts, grated horseradish root. To use drugs from pressure is tiresome for 1 tbsp. Several times a day.
With vasculitis, a good effect is provided by herbal treatment. The medical fees include yarrow (grass), nettle (leaves), sporish (grass), elderberry (flowers), Japanese souphora (fruits). Useful in terms of treatment of vasculitis will be: calendula (flowers), string (grass), licorice (root) and other medicinal plants.
To the treatment of reticular lyvedo and various vascular pathologies with the help of homeopathy, doctors are advised to treat with a certain degree of caution. Especially when it comes to reducing the viscosity of the blood.
There are many effective and safe alternative recipes for blood thinning, which have a less pronounced effect than homeopathic drugs. Remember that when idiopathic livedo doctors recommend small doses of "Aspirin", which will not cause hemorrhages from the vessels.
And in order to combat high blood pressure, homeopathy is quite applicable. Useful are the salts of barium (preparations Barite Carbonate, Barita Moireiatika in 3 and 6 dilutions) and salt of gold. In addition, Sekale and Adrenaline in 6 and 12 dilutions, Acidum phosphoricum and Nuks vomica in 3 and 6 dilutions, Veratrum virida in 3X potency and others affecting peripheral vessels and blood flow in them are used.
But the following homeopathic remedies have a positive effect on the vessel walls: Arnica (potency 3X), Potassium phosphoricum in 6 dilutions and again Nux vomica in 3 or 6 dilutions.
The prescription of the above drugs should only be handled by a professional homeopathic physician after setting the actual diagnosis, otherwise the treatment may be ineffective, and in some cases, also cause a cut in the patient's health.
Prevention of the liver consists in preventing supercooling of limbs and the body, the use of thermal procedures, dosed physical exercise: running, walking (especially walking barefoot on heterogeneous surfaces, hot sand, alternately on hard and soft surfaces), exercising on exercise bikes to improve heart function.
Effective also regular cleaning of vessels to prevent atherosclerosis. For this, you can use ordinary boiled water, which must be drunk in the morning on an empty stomach in the amount of 1 cup.
Normalize the pressure and remove salt from the body, settling on the walls of the vessels, you can use alternative means (tincture of wild rose, Melissa infusion, decoction of sophora, etc.), which can be used instead of tea.
Contain the vessels in the norm and avoid the appearance of a marble pattern on the body, which characterizes the net liver, the masses and water procedures (ideally the contrast shower) will help the masses, and, of course, proper nutrition, walks in the fresh air, rejection of bad habits, regular physical examinations, attentive attitude to their health.
An idiopathic reticulum, which is sometimes also called benign, without the attachment of a lidado vasculitis has a quite favorable prognosis and does not affect the health of patients.
The prognosis of the symptomatic livestock depends entirely on the pathology that caused the appearance of the marble pattern on the body, the timeliness of seeking help, the severity of the disease, the performance of the doctor's prescriptions for the underlying disease.
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